Darth Vader's Respiratory Failure (2016) - A Case Study - PDF

Figure 1. An advanced bi-level positive airway pressure system integrated in a whole-body armoured suit for the treatment of acute and chronic respiratory...

Figure 1. An advanced bi-level positive airway pressure system integrated in a whole-body armoured suit for the treatment of acute and chronic respiratory failure in a Sith Lord. © LucasArts 30 Physiology News / Summer 2016 / Issue 103  Features Breath of the Sith: a case study on respiratory failure in a galaxy far, far away Spoiler alert! While the eagerly awaited seventh instalment in the Star Wars saga has thrilled physiologists and non-physiologists alike, it may be worthwhile to take a look back at what we as respiratory physiologists have learned from the venerated space opera so far. It remains indisputable – at least between the authors of this paper – that the first six episodes’ protagonist-turned-villain-turned-saviour Anakin Skywalker/ Darth Vader is the most fascinating case study on respiratory failure in the history of cinema. The enigmatic breathing sounds produced by his iconic whole-body armoured suit, as well as his mysterious underlying respiratory condition, have been source of bewilderment and Ronan Berg fascination (and fright) to at least two aspiring respiratory physiologists that grew up in the outskirts of Denmark during the Department of Clinical Physiology 1980s, a time when every child dreamt of becoming either a Jedi Knight & Nuclear Medicine, Frederiksberg or a Stormtrooper. and Bispebjerg Hospitals, Copenhagen, Denmark Health hazards of volcanic fumes Prior to the tragic events on Mustafar, Vader’s health and fitness level are seemingly In the Star Wars saga, the highly talented excellent. Even though the air on a volcanic Jedi knight, Anakin Skywalker, choses to planet is mostly composed of water vapour, abandon the monastic Jedi Order and instead carbonic and sulphuric gases, and nitrogen, join his father figure Sheev Palpatine in the with insignificant levels of oxygen (Cadle more exclusive and politically involved Sith 1980), Darth Vader and his former Jedi Order. As he does this, he assumes a new Master readily engage themselves in the identity as Darth Vader, and earns the title intense and extremely physically challenging Dark Lord of the Sith. For a number of light sabre duel in this climate (probably the reasons, this change of careers does not equivalent of an hour-long high-intensity impress a former Jedi Master of his, and the exercise bout at the summit of Mount two soon clash in a light sabre duel on the Everest), without ever taking even a short volcanic planet Mustafar. The confrontation break to catch their breath. After the results in a near-fatal outcome for Darth incident, Darth Vader is, however, unable to Vader who loses several limbs in the fight, breathe freely at all; outside his personal Ronni Plovsing and while he is incapacitated on the volcanic shore, he furthermore suffers inhalational meditation chamber, which also appears to function as some kind of a fancy hyperbaric Department of Intensive Care 4131, injury and third degree burns. However, oxygen facility, he continually relies on a before he passes away, Palpatine comes to mobile life-support system, which is University Hospital Rigshospitalet, integrated in a whole-body armoured suit, the rescue, and organises timely medical Copenhagen, Denmark intervention. in order to survive (Figure 1). 31  40 30 20 10 ‘We deem it irrefutable that Darth Vader fulfils 0 the diagnostic criteria Resting Normal Stressful Exercise conditions everyday situations for acute respiratory activities distress syndrome within a few hours Figure 2. Respiratory rate according to activity level in a Sith Lord (n =1). Data are obtained from Plovsing & Berg (2014) and presented as mean (± standard deviation). ‘Rest’ includes after the incident on recreational activities in a meditation chamber; ‘Normal everyday activities’ include various friendly encounters as well as torture of enemies, colleagues, and employees; ‘Stressful Mustafar’ situations’ includes increased alertness and arousal; ‘Exercise’ includes running, combat and light sabre duels. Darth Vader’s acute respiratory failure compartment. These induce alveolar appears to be the consequence of a number inflammation with oedema formation, and of factors, including direct thermal injury to impair mucociliary function and surfactant the airways, chemical damage to the lung production, but do not usually cause parenchyma caused by inhalation of smoke symptoms until after several hours. Many and volcanic dust particles, carbon volcanic aerosols have an aerodynamic monoxide poisoning, as well as secondary diameter of less than 5 μm, and are thus effects to his severe third degree burns, easily dispersed in the peripheral airways, which seems to cover ~100 % of his total where they may cause similar effects to gas body surface area. irritants with low water solubility. Thermal injury caused by scalding volcanic Inhalation-induced acute respiratory fumes primarily affects the central parts of distress syndrome in a Sith Lord the lungs, because the dissipation of heat results in less damage to the peripheral areas Darth Vader’s immediate respiratory distress (Eyal et al., 1975). This causes oedema in the on the volcanic shore is probably caused by large airways, as well as peribronchial and volcanic gaseous irritants with high water perivascular haemorrhages, and acutely solubility in the volcanic fumes, which cause reduces pulmonary compliance, but without immediate symptoms of tracheobronchitis, any marked effects on pulmonary gas and impair pulmonary gas exchange (Nemery exchange within the first few hours. In 2006; Mlack et al., 2007). Since Darth Vader addition, so-called pyroclastic density currents, may concurrently be exposed to high levels of volcanic gases that move laterally near the carbon monoxide, which both impairs the red ground at hurricane velocities, may induce blood cell uptake of oxygen in the lungs due immediate thermal injury beyond the central to its higher affinity for haemoglobin than parts of the lungs (Hansell et al., 2006). oxygen, and furthermore shifts the oxygen- haemoglobin saturation curve to the left, so Volcanic fumes furthermore contain that the release of oxygen from the red blood numerous irritants that cause chemical cells to tissue mitochondria (and perhaps also damage to the airways (Nemery 2006). the conceivably similar midi-chlorians) in Gaseous irritants with high water solubility, various organs is impaired; severe tissue such as ammonia and sulphuric dioxide, are hypoxia therefore ensues. Due to his quite mainly trapped in the aqueous surface of the severe facial burns, it is difficult to determine upper respiratory tract, and give rise to whether Darth Vader exhibits ‘cherry-red immediate symptoms. They cause airway wall cheeks’ at this stage, a typical clinical finding oedema, bronchospasm, ulcerations, and associated with carbon monoxide poisoning, necrosis in the conductive airways. Volcanic but his rather agitated emotional state is gas irritants with a low water-solubility, such characteristic of the cerebral dysfunction as nitrogen oxides, may pass the upper often encountered in this clinical condition. airways and eventually reach the alveolar 32 Physiology News / Summer 2016 / Issue 103 Within a few hours, that is, after Darth Vader Since Darth Vader continually relies on the has been evacuated by Palpatine, the effects whole-body armoured suit, the acute effects of direct thermal injury on the central parts of the thermal and chemical injury must have of the lungs, as well as the effects of the led to lung fibrosis due to extensive scar tissue volcanic water soluble gaseous irritants and formation in the pulmonary parenchyma, aerosols set in. These give rise to acute which permanently reduces ventilatory chemical pneumonitis with non-cardiogenic capacity on a restrictive basis and impairs gas pulmonary oedema and induce a reduction in exchange by increasing ventilation-perfusion ventilatory capacity with increased pulmonary inequality (Plovsing & Berg, 2014). It is less ventilation-perfusion inequality, thus severely clear whether he also suffers from chronic impairing pulmonary gas exchange (Nemery bronchitis, which could add a obstructive 2006). At this stage, the systemic component to his lung disease. In contrast to References inflammatory response to the severe skin General Grievous, the Supreme Commander burns may furthermore disseminate from the of the Confederacy of Independent Systems Cadle RD (1980). A comparison of volcanic with other blood stream to the alveolar compartment, during the Clone Wars, who is a clear-cut fluxes of atmospheric trace gas constituents. Rev and thus exaggerate the pulmonary case of chronic bronchitis with a rattling cough, Geophys 18, 746-52 inflammatory response. Although appropriate Darth Vader is never once observed to cough diagnostic imaging would be required to during the Star Wars saga. On the other hand, Hansell AL, Horwell CJ, Oppenheimer C (2006). The establish the diagnosis here on Earth, we deem he clearly has the appearance of a ‘blue health hazards of volcanoes and geothermal areas. Occup Env Med 63, 149-56 it irrefutable that Darth Vader fulfils the bloater’ with bluish colour of the skin and lips, diagnostic criteria for acute respiratory and develops severe wheezing when Luke Eyal Z, Dunsky EH, Polliack A, Davidson JT (1975). distress syndrome within a few hours after the Skywalker detaches his mask in Episode VI The acute effect of pulmonary burns on lung incident on Mustafar, which is a common (Figure 3). These are characteristic features mechanics and gas exchange in the rabbit. complication both after inhalation injury and of chronic bronchitis, and the lack of coughing Br J Anaesth 47, 546-52 severe skin burns (Mlack et al., 2007). from the Sith Lord thus rather reflects the efficacy of the treatment with the whole- Mlcak RP, Suman OE, Herndon DN (2007). Following extensive robotic surgery, the body armoured suit than it reflects absence Respiratory management of inhalation injury. medical droids choose to treat Darth Vader’s of obstructive pulmonary disease. Burns 33, 2-13 respiratory condition by means of the iconic whole-body armoured suit. The suit contains Conclusion Neff TA, Stocker R, Frey HR, Stein S, Russi EW a mobile life-support system, and from a (2003). Long-term assessment of lung function in careful analysis of Episodes IV-VI, we have Our extensive analysis of the first six survivors of severe ARDS. Chest 123, 845-853 concluded that it functions as an advanced instalments of the Star Wars saga bi-level positive airway pressure (BPAP) demonstrates that Darth Vader suffers from Nemery B (2006). Chemical-induced lung injury and its long-term sequelae. In: Imaging of Occupational system that supports Darth Vader’s intrinsic the chronic aftermath of acute respiratory and Environmental Disorders of the Chest. Springer breathing both during in- and expiration, distress syndrome caused by inhalation-injury Berlin Heidelberg, pp. 67-75. while preventing airway collapse, and and skin burns, which is treated by a whole- continually supplying him with oxygen body armoured suit that features an advanced Perrella A, Russo C, Giuliani A, Esposito C, Saturnino P (Plovsing & Berg 2014). Accordingly, his BPAP system. The findings of our study stress (2015). Infection control in a far, far away Galaxy: respiratory rate varies with his activity level that volcano-associated pulmonary injury is new and alternative learning tool from popular (Figure 2), and pressure equalisation with far from trivial, and furthermore that acute culture to improve the antimicrobial stewardship. the surroundings can clearly be heard when respiratory distress syndrome and its North Am J Med Sci 7, 236-7 his helmet is detached. Other scientists have complications are diagnostic entities that noted that Darth Vader’s whole-body extend way beyond the traditional intensive Plovsing RR, Berg RMG (2014). Pulmonary armoured suit may furthermore function as a care setting. pathophysiology in another galaxy. means of preventing infections, which is Anesthesiology 120, 230-2 notably relevant in the immediate aftermath of the events on Mustafar, due to Darth Vader’s extensive skin burns (Perrella et al., 2015). Dark Lord of the Sith: A blue bloater in disguise? Studies have shown that patients with acute respiratory distress syndrome, including those that involve thermal and/or inhalational lung injury, suffer from permanent reductions in ventilatory capacity as well as impaired pulmonary gas exchange after discharge from hospital (Neff et al., 2003). This also appears to be the case for Darth Vader, despite the timely intervention by Palpatine’s medical droids. Hence, as we encounter Vader in Episode IV, two decades after the events on Mustafar in Episode III, it is clear that the Figure 3. ‘Blue bloater’: beneath the mask, treatment with the whole-body armoured Darth Vader exhibits the characteristic suit has been maintained during all the physical symptoms of chronic bronchitis. intervening years. © LucasArts 33 View publication stats